Research Article Assessing and Comparing Global …downloads.hindawi.com/journals/rerp/2013/208187.pdfResearch Article Assessing and Comparing Global Health Competencies in Rehabilitation

Hindawi Publishing CorporationRehabilitation Research and PracticeVolume 2013, Article ID 208187, 9 pageshttp://dx.doi.org/10.1155/2013/208187

Research ArticleAssessing and Comparing Global Health Competencies inRehabilitation Students

Mirella Veras,1 Kevin Pottie,2 Debra Cameron,3 Govinda P. Dahal,4,5

Vivian Welch,6 Tim Ramsay,7 and Peter Tugwell8

1 University of Ottawa/Saint Elizabeth Health Care, Nursing Best Practice Research Center, University of Ottawa,1118E, 451 Smyth Road, Ottawa, ON, Canada K1H 8M5

2Departments of Family Medicine and Epidemiology and Community Medicine, University of Ottawa,1 Stewart Street, Ottawa, ON, Canada K1N 6H7

3Department of Occupational Science and Occupational Therapy, University of Toronto,Room 160, 500 University Avenue, Toronto, ON, Canada M5G 1V7

4 Institute of Population Health, Faculty of Medicine, University of Ottawa, 1 Stewart Street, Ottawa, ON, Canada K1N 6H75 Canada Foundation for Nepal, Canada6Bruyere Research Institute, University of Ottawa, 1 Stewart Street, Ottawa, ON, Canada K1N 6H77Ottawa Hospital Research Institute, Clinical Epidemiology Program, 1 Stewart Street, Ottawa, ON, Canada K1N 6H78Departments of Family Medicine and Epidemiology and Community Medicine, 1 Stewart Street, Ottawa, ON, Canada K1N 6H7

Correspondence should be addressed to Mirella Veras; [email protected]

Received 6 March 2013; Revised 26 September 2013; Accepted 3 October 2013

Academic Editor: Richard Crevenna

Copyright © 2013 Mirella Veras et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Purpose. Globalization is contributing to changes in health outcomes and healthcare use in many ways, including health pro-fessionals’ practices. The objective of this study was to assess and compare global health competencies in rehabilitation students.Method. Online cross-sectional survey of physiotherapy and occupational therapy students from five universities within Ontario.We used descriptive statistics to analyze students’ perceived knowledge, skills, and learning needs in global health. We used Chi-square tests, with significance set at 𝑃 < 0.05, to compare results across professions. Results. One hundred and sixty-six studentscompleted the survey. In general, both physiotherapy and occupational therapy students scored higher on the “relationship betweenwork andhealth,” “relationship between income andhealth,” and “socioeconomic position (SEP) and impact on health” and lower on“Access to healthcare for low income nations,” “mechanisms for why racial and ethnic disparities exist,” and “racial stereotyping andmedical decision making.” Occupational therapy students placed greater importance on learning concerning social determinantsof health (𝑃 = 0.03). Conclusion. This paper highlights several opportunities for improvement in global health education forrehabilitation students. Educators and professionals should consider developing strategies to address these needs and provide moreglobal health opportunities in rehabilitation training programs.

1. Introduction

Globalization has become a key word in the 21st century andis defined here as “the ways in which nations, businesses,and people are becoming more connected and interdepen-dent across national borders through increased economicintegration, communication, cultural diffusion, and travel”[1]. Indeed, globalization has influenced health determinantsand changed health outcomes [1]. The social determinantsof health (SDH), including health services, are influenced by

the distribution of money, power, and resources at global,national, and local levels [2–4]. In addition, natural disasterssuch as floods, earthquakes, and volcanic eruptions as wellas complex emergencies including war, civil strife, and foodshortages are now considered global problems which have aconsiderable impact on population health worldwide [5].

Evidence shows that such calamities have progressivelyincreased the number of deaths, illnesses, and disabilities and,therefore, the economic costs of treatment and rehabilitation[5]. For instance, the earthquake that occurred in Haiti in

2 Rehabilitation Research and Practice

2010 resulted in extensive infrastructure damage, and it wasestimated that there were 220 000 casualties and more than300 000 people suffered from injuries including fractures,burns, amputations, and brain and spinal cord injuries [6, 7].Additionally, there is an increase in the number of peoplewithchronic diseases in both developed and developing countries,which may lead to their development of several disabilities[5]. These health issues highlight the role that rehabilitationprofessionals, such as occupational therapists and physiother-apists, play in improving daily living and functional skills inpeople who have suffered from exposure to natural disastersand chronic conditions and their implication on global health[7].

Presently, there is an extraordinary interest in globalhealth among students, health professionals, and educators[8]. Some universities have departments or units that focuson global health and offer opportunities, specifically, to phys-iotherapists and occupational therapists to work overseas[9, 10]. For example, The International Centre for Disabilityand Rehabilitation (ICDR) at the University of Toronto hasencouraged a focus on global health issues related to disabilityand rehabilitation within the rehabilitation sciences. Thenumbers of students who have had the opportunity toexperience an international clinical internship has increasedsignificantly in the past ten years [11].

Occupational therapists and physiotherapists have beenparticipating in paid and unpaid work overseas as wellas international internships as part of their educationalprograms [7, 12]. The World Confederation for PhysicalTherapy (WCPT) carries out several programs and projectsfor physiotherapists working overseas as well as supportinginternational campaigns to endorse the contribution of theprofession for global health [13]. The president of the WorldFederation for OccupationalTherapists (WFOT) emphasizesthe commitment of the profession to contribute to globalhealth and the World Health Organization (WHO) initia-tives, which includes several topics for the global healthagenda: mental health, human resource planning, healthyaging, actions for health and well-being, and disability [14].

Research on disability and health care suggests that peo-ple with impairments face noteworthy personal and culturalbarriers to access healthcare facilities. The personal barri-ers are related to transportation, communication, finance,and insurance. The cultural barriers include misconceptionsabout people with disabilities, lack of respect, and reluctanceto provide care for these populations [15]. Although there isan increased interest in global health, little is known aboutthe global health competencies of occupational therapy andphysiotherapy students. Hence, the purpose of this study isto assess the knowledge, skills, and learning needs related toglobal health and health equity of occupational therapists andphysiotherapists students in Ontario, Canada.

2. Methods

Anonline cross-sectional surveywas administered using Sur-veyMonkey online survey to physiotherapy and occupationaltherapy students registered in five universities in Ontario.

2.1. Instrument. A forty-seven-item online global healtheducation survey was firstly developed to gather informa-tion regarding self-perceived knowledge, skills, and learn-ing needs in global health. The survey was developed byadapting three other instruments: (1) resident physicians’knowledge of underserved patients, a validated survey used tomeasure actual and perceived resident physician’s knowledgeof underserved patient populations in the United Statesdone by Wieland and adapted by the research team for theCanadian population (17 items) [16]; (2) a global healthcompetency skills survey formedical students by Augustincic(14 items) [17]; (3) the Canadian Medical Education Direc-tives for Specialists (CanMEDS) competencies as [18]. Thesurvey consisted of questions subdivided into four parts:(1) knowledge in global health and health equity (3-pointscale); (2) global health skills (5-point scale); (3) learningneeds about global health (16 items) (5-point scale); and (4)about you: demographic and socioeconomic questions. Thisglobal health education survey was described previously anddemonstrates good internal consistency with a Cronbach’salpha > 0.8 [19]. The full analysis of the global healtheducation survey was described in a previous publication[20].

The questions regarding self-assessed confidence inglobal health (part 01/04) asked respondents whether theyfelt “not at all confident,” “somewhat confident,” or “veryconfident.” The questions received the following code: 0 (notat all), 0.5 (somewhat), and 1 (very). Self-perceived skillsin global health (part 2/4) could be answered by either“strongly agree,” “agree,” “neutral,” “disagree,” or “stronglydisagree.” The questions received codes varying between 0and 1 (item scale [0-1]—for negative questions: 1 = stronglydisagree, 0.75 = disagree, 0.50 = neutral, 0.25 = agree, and0 = strongly agree; for positive questions: 1 = strongly agree,0.75 = agree, 0.50 = neutral, 0.25 = disagree, and 0 = stronglydisagree). Therefore, by averaging all respondents’ answersto a given question and multiplying that average by 100,each question was given a number between 0 and 100. Thescore 0 represented a complete lack of confidence and 100represented feeling completely confident. Learning needs inglobal health (part 3/4) could be answered by either “not atall important,” “somewhat important,” “neutral,” “important,”“very important,” or “extremely important.” The fourth partof the survey included demographic questions.

2.2. Participants. Students from five universities, withinOntario, Canada, were invited to participate in the study.Inclusion criteria were predefined as follows: 18 years or olderor 1st year student from a master’s program in physiotherapyor occupational therapy program in one of the five participat-ing universities in Ontario.

2.3. Data Collection. From May to October 2011, directorsor coordinators of physiotherapy and occupational therapyprograms were contacted to collaborate the survey. Theywere asked to send an e-mail invitation to all physiotherapyand occupational therapy students to invite the prospectsto participate in the survey. Then, an e-mail containing

Rehabilitation Research and Practice 3

Table 1: Demographic characteristics of respondents (𝑁 = 166).

VariablesNumber (percentage)

Physiotherapy students𝑛 = 68

Occupational therapystudents 𝑛 = 98

SexMale 13 (19.1) 5 (5.1)Female 55 (80.9) 93 (94.9)

Country (of birth)Canada 59 (86.8) 87 (88.8)United States 0 (0.0) 1 (1.0)Philippines 1 (1.5) 1 (1.0)India 1 (1.5) 0 (0.0)Honk Hong 3 (4.4) 3 (3.1)Pakistan 0 (0.0) 1 (1.0)Other 4 (5.9) 5 (5.1)

Mean age 26.47 (41) 24.91 (59)Family background

White 52 (76.4) 78 (79.6)Chinese 7 (10.3) 7 (7.1)South Asian 3 (4.4) 6 (6.1)Black 0 (0.0) 1 (1.0)Other 6 (8.8) 6 (6.1)

Parent’s family income$20,001 to $30,000 8 (11.8) 1 (1.0)$30,001 to $40,000 1 (1.5) 3 (3.1)$40,001 to $50,000 4 (5.9) 3 (3.1)$50,001 to $60,000 2 (2.9) 8 (8.2)$60,001 to $70,000 4 (5.9) 4 (4.1)$70,001 to $80,000 5 (7.4) 10 (10.2)$80,001 or more 23 (33.8) 34 (34.7)Do not know 21 (30.9) 35 (35.7)

Languages (spoken)One language 26 (38.2) 48 (49.0)Two languages 31 (45.6) 38 (38.8)Three languages 8 (11.8) 6 (6.1)Four languages or more 3 (4.4) 6 (6.1)

a hyperlink to the survey and a consent form was sent toall students. Two reminder e-mails were sent at one and twoweek intervals.

2.4. Ethical Considerations. Ethical approval was obtained forthis study from the Ottawa Hospital Research Ethics Board,the University of Ottawa, and the University of WesternOntario.

3. Results

The response rate was 23.7% and thus a total of 166 par-ticipants were included in the following analysis. Most ofthe participants were females, originally from Canada, from

a higher socioeconomic background and were able to speakat least two languages.

3.1. Participant’s Characteristics. All five eligible universitieswhich offered both physiotherapy and occupational therapyprograms in Ontario, Canada, were represented in this study.Table 1 shows the demographic characteristics of respon-dents. Most of the participants in both programs were female(81% physiotherapy students (PTS) and 95% occupationaltherapy students (OTS)). The majority of the respondentswere born in Canada (87% physiotherapy students and 89%occupational therapy students). The physiotherapy partici-pants were older (mean age = 26.47 years) than occupationaltherapy students (mean age = 24.91 years). The majority of


Table 2: Physiotherapy and occupational therapy students’ self-perceived knowledge in global health.

Domains of self-perceived knowledge Physiotherapy students’ score∗(%)

Occupational therapy students’score∗ (%)

Language barrier and adverse impact on health and healthcare 65.67 57.65

Access to health care for low income nations 25.74 29.59Relationship between income and health 71.32 76.53Relationship between work and health 68.38 81.63SEP and impact on health 64.71 67.86Environmental health and socioeconomic position 47.06 53.06Relationship between housing and health status 55.15 54.12SEP and food security confidence 54.41 48.47Health outcome discrepancies among different groups inCanada 39.71 40.82

Mechanisms for why racial and ethnic disparities exist 32.35 31.12Racial stereotyping and medical decision making 36.76 38.54Gender and access to health care 42.65 40.82∗Average perceived knowledge and skills percentage for each domain varied for item scale between 0 and 1 (item scale [0-1]: 0 = not at all confident; 0.5 =somewhat confident; 1 = very confident).

participantswere fromawhite family background (77%phys-iotherapy students and 80% occupational therapy students).Slightly more than one third of interviewed students of bothcategories had parents with an annual income of CAN$80,000 or greater. Physiotherapy students had relativelyhigher multilingual abilities compared to their counterpartsfrom occupational therapy (Table 1).

3.2. Self-Perceived Global Health Knowledge Scores. Studentswere asked to rate their self-perceived knowledge in severalglobal health and health equity topics. The self-perceivedknowledge scores of physiotherapy and occupational therapystudents in twelve domains of global health are presented inTable 2. Self-perceived knowledge of physiotherapy studentswas found to be highest (71%) in “relationship betweenincome and health” followed by “relationship between workand health” (62%) and “language barrier and adverse impacton health and health care” (66%). Similarly, self-perceivedknowledge of occupational therapy students was highestin “relationship between work and health” (82%) domainfollowed by “relationship between income and health” (77%)and “socioeconomic position (SEP) and impact on health”(68%) (Table 2).

3.3. Self-Perceived Global Health Skills for Physiotherapy andOccupational Therapy Students Guided by the CanMEDSFramework. The scores of perceived global health skills ofphysiotherapy and occupational therapy students in elevenskills domains guided by the CanMEDS framework arepresented in Table 3. Both physiotherapy and occupationaltherapy students perceived themselves to have higher globalhealth skills in (i) listening (PS = 76% and OTS = 73%), (ii)clinical competency (PS = 70% and OTS = 67%), and (iii)identifying needs (PS = 63% and OTS = 57%) and having

lower skills in (iv) being active in global health (PS = 33% andOTS = 33%) domains.

3.4. Learning Needs in Global Health. Learning needs inglobal health for physiotherapy and occupational therapystudents are presented in Table 4. Participants considered it“extremely important” to learn about the topic “understandthe relationship between health and human rights” and “notat all important” to learn about the “relationship betweenaccess to clean water, sanitation, and nutrition on individualand population health.” Statistically significant relationshipsbetween variables considered for learning needs in globalhealth were assessed using chi-square test. The results showthat there was a significant result for the following top-ics: “relationship between health and social determinantsof health and how social determinants vary across worldregions” (𝑃 = 0.03) and “relationship between access to cleanwater, sanitation, and nutrition on individual and populationhealth” (𝑃 = 0.03).

Almost 70% of the occupational therapy studentsreported that it is extremely important to learn about therelationship between health and social determinants of healthand how social determinants vary across world regionscompared to 31% of physiotherapy students (𝑃 = 0.03).Additionally, almost 80% of the occupational therapystudents considered that “relationship between access toclean water, sanitation, and nutrition on individual andpopulation health” is a very important topic to learn in globalhealth compared to 21% of physiotherapy students (𝑃 = 0.03)(Table 4).

Both physiotherapy and occupational therapy students(a total of 25 students) suggested additional topics that areimportant to learn in global health including (1) “under-standing the different structures of health care around theworld,” (2) “access to adequate healthcare services in less


Table 3: Perceived global health skills for physiotherapy and occupational therapy students guided by the CanMEDS framework.

Skills Physiotherapy students’ score∗(%)

Occupational therapy students’score∗ (%)

Communication skills 60.00 54.34Listening skills 76.17 72.68Able to understand patient with different backgroundskills 54.04 56.63

Address team disagreement skills 52.69 42.89Discuss sensitive issues skills 49.62 48.95Identify needs skills 63.28 56.84Helping patients achieve realistic goals skills 55.68 47.83Working in a team skills 55.47 53.95Clinical competency Skills 69.62 67.11Keep up to date in global health skills 50.47 53.16Active in global health skills 33.09 33.42∗Average perceived knowledge and skills percentage for each domain varied for item scale between 0 and 1 (item scale [0-1]: for negative questions: 1 = stronglydisagree, 0.75 = disagree, 0.50 = neutral, 0.25 = agree, 0 = strongly agree); for positive questions (1 = strongly agree, 0.75 = agree, 0.50 = neutral, 0.25 = disagree,0 = strongly disagree).

developed countries,” (3) “cultural perceptions of disabil-ity, work and health,” (4) “global health issues and socialdeterminants of health,” (5) “language barrier and effectivecommunication,” (6) “Potential cultural clash experiences ofyoung immigrants, stereotyping based on religion, knowingthe effects politics has on health in certain countries in theworld,” (7) “the impact of climate change on the health of lowsocioeconomic classes,” (8) “specific education surroundingaboriginal people and the effects that their lifestyles have onthem physically, psychologically, and emotionally,” and (9)“WHOmillennium development goals.”

4. Discussion

Our study identified several knowledge and skill opportu-nities relevant to global health and health equity for reha-bilitation sciences students. These needs overlap with otherprimary health professionals but differ between professions,suggesting a need for both interprofessional and intrapro-fessional prioritization for education and policy relevance.Overall, both occupational therapy and physiotherapy stu-dents demonstrated limited competencies in global health.Few items received scores over 60%.

Most participants in our survey were females that spoketwo languages and came from families with high socioeco-nomic status. The students’ sociodemographic profile is animportant component for effective care in a global healthcontext. The recent report by the Commission on EducationofHealth Professionals for the 21st century refers that inmanycountries the competencies of graduate studentsmight not bealigned with the new challenges and the social, linguistic, andethnic diversity of the populations [21]. Our findings confirmthe results of the recent commission report which states thathealth professional students admitted in health programscome from higher social classes and dominant ethnic groups[21].

Regarding gender, our findingswere consistentwith thoseofCockrell andPeplau [22, 23] that there is a predominance offemales in health programs.Moreover, the Canadian Institutefor Health Information (CIHI) 2009 report also found thatoccupational therapists had higher proportion of women intheir workforce (92.0%) compared to various other healthprofessions, such as physiotherapists (78.0%), pharmacists(59.2%), and physicians (34.7%) [24]. This evidence validatesthat females dominate the workforce of physiotherapy andoccupational therapy in all provinces of Canada [24].

Gender balance in health systems is highly recom-mended, as a gender imbalance is a major obstacle foraccess to health care [25, 26]. There is extensive literatureon “feminization” of parts of the health workforce and highconcentration of women in health professions. This trendis directly related to globalization and it has consequencesto global health. It can bring many consequences for healthsystems, such as practice location and practice hours. Femaleprofessionals are more likely to practice in urban areasrather than rural areas [27]. Globally, nearly one half of thepopulation lives in rural areas and, according to the WHO,the health professional workforce shortage in rural areas is aworldwide problem that affects almost all countries [28]. TheWHOalso recommends admission policies to enroll studentswith a rural background in order to increase the probabilityof these students developing their practice in rural areas [28].Moreover, a number of studies have documented that womenwork fewer hours in their professional careers than do men[29].

In our study, almost half of the physiotherapy studentparticipants self-reported that they are able to speak at leasttwo languages while half of the occupational therapy studentparticipants reported that they are only able to speak onelanguage. In addition, more than 60% of the physiotherapyparticipants reported self-perceived confidence related tolanguage barriers and adverse impact on health and health


Table 4: Learning needs in global health for physiotherapy and occupational therapy students in Ontario, Canada.

Learning needs in global health Physiotherapy𝑁 (%) Occupational therapy𝑁 (%) Pearson chi-squareHealth risks associated with travel and migration, withemphasis on possible risks and appropriatemanagement, including referrals

Not important 0 (0) 0 (0)Somewhat important 16 (64) 9 (36) 0.12Neutral 7 (28) 18 (72)Important 24 (40.7) 35 (59.3)Very important 16 (40) 24 (60)Extremely important 4 (36.4) 7 (63.6)

Knowledge about how travel and trade contribute to thespread of communicable diseases

Not important 0 (0) 0 (0)Somewhat important 9 (42.9) 12 (57.1) 0.86Neutral 9 (33.3) 18 (66.7)Important 27 (45.8) 32 (54.2)Very important 15 (45.8) 20 (57.1)Extremely important 7 (38.9) 11 (61.1)

Relationship between health and social determinants ofhealth, and how social determinants vary across worldregions

Not important 0 (0) 0 (0)Somewhat important 3 (75) 1 (25) 0.03Neutral 5 (62.5) 3 (37.5)Important 28 (53.8) 24 (46.2)Very important 17 (32.7) 35 (67.3)Extremely important 15 (31.3) 33 (68.8)

Relationship between access to clean water, sanitation,and nutrition on individual and population health

Not important 2 (50) 2 (50) 0.03Somewhat important 4 (40) 6 (60)Neutral 5 (55.6) 4 (44.4)Important 18 (36) 32 (64)Very important 9 (20.9) 34 (79.1)Extremely important 30 (62.5) 18 (37.5)

Understand the relationship between health and humanrights

Not important 1 (50) 1 (50) 0.28Somewhat important 2 (66.7) 1 (33.3)Neutral 4 (50) 4 (50)Important 18 (43.9) 23 (56.1)Very important 14 (27.5) 37 (72.5)Extremely important 29 (47.5) 32 (52.5)

Knowledge about how global health institutions (e.g.,WHO, other United Nations agencies, and globalinstitutions) influence health in different world regionsthrough funding and policy

Not important 1 (33.3) 2 (66.7) 0.74Somewhat important 2 (50) 2 (50)Neutral 6 (54.5) 5 (45.5)Important 24 (46.2) 28 (53.8)Very important 22 (35.5) 40 (64.5)Extremely important 12 (36.4) 21 (63.6)


care. According to the literature, one of the barriers to effec-tive health care services is language [30, 31]. Multilinguisticknowledge and skills help health professionals to provideeffective care for their clients. This finding is compatiblewith a similar survey about self-perceived knowledge ofunderserved population topics with family physician resi-dents in United States (Wieland Survey) where they reported61.0% had confidence in this topic [16]. From the serviceprovider’s perspective, language may be a barrier to thehealth professionals in understanding the information andbeliefs regarding patients’ health and address the differenceor incongruence in the values of patients and physiotherapistsand occupational therapists [32].

On the other hand, our result in relation to the confidencein the “relationship between income and health” differs fromthe Wieland study. More than 80% of the occupationaltherapy students assessed themselves as confident in the“relationship between income and health,” while 57.4% of USfamily physician residents surveyed reported confidence inthe topic. We believe that this difference is related to themain role of the occupational therapists. The occupationaltherapy profession in itself has a crucial role in training andoffering advice on occupational performance, including self-care and productive and recreational activities [26]. Theirinterventions are also very effective for reducing personaland societal costs of work-related injuries as well as reducingthe duration of work disabilities [26]. Hence, knowledgein “relationship between income and health” is a crucialcompetence for occupational therapists in all settings andtherefore their confidence in this area is not surprising.

Physiotherapy and occupational therapy studentsreported less confidence in “access to health care for lowincome nations,” “mechanisms for why racial and ethnicdisparities exist,” and “racial stereotyping and medicaldecision making.” For these topics, our results were similarto the US students survey, where all of them scored lessthan 50% [16]. Socioeconomic status and racial disparitiesare important determinants of health outcomes [33, 34] andare extremely important for working with a global healthperspective.

Overall, students from both programs reported less skillin “global health activity.” Physiotherapists and occupationaltherapists need to have extended knowledge and skills inglobal health in addition to their core professional training,to tackle the global burden of disease and disabilities in thismulticultural world of the 21st century. The complexity ofglobal health work demands physiotherapists and occupa-tional therapists to have not only clinical and rehabilitationabilities, but also skill and knowledge regarding epidemi-ology, sociology, population health, geography, laws, andother disciplines. These disciplines are crucial for workingin partnership with governmental and nongovernmentalorganizations.

Another point of emphasis is that in this globalized worldoccupational therapists and physiotherapists must build con-fidence to meet the demand and quality care of internationalcitizens from all over the world, including immigrants andrefugees, disabled people, victims of wars, and those whosuffer from infectious diseases in order to provide equitable

services. Furthermore, all the global health challenges willcome to “knock on the door” of all health professionalswherever they are working in different settings sectors, suchas clinics, rehabilitation centers, community health, or inhospitals.

4.1. Strengths and Limitations of the Study. This study beginsto address important knowledge gaps that have appearedin global health literature and provides some global healthrelevant elements for the disciplines of physiotherapy andoccupational therapy. It also highlights how future studentsof these disciplines can address the growing needs of globalhealth effectively and equitably. Although the findings ofthis study are important, the results of this study shouldbe interpreted with caution and should not be generalizedfor all populations because of the small sample size andthe limited response rate. We used several strategies toimprove the response rate such as e-mail and/or phone callcommunications with the coordinator and/or responsible forthe health programs in the five universities in Ontario, inorder to engage them in the research and two reminderswere sent to the participants within two-week interval.Unfortunately, these strategies were not enough to minimizethe low response rate already expected. Another limitation ofthe research was the availability of the survey only in English.Some health programs are offered only in French and eventhough we sent an e-mail invitation to the participants inFrench, it was not sufficient to motivate French speakingstudents to participate.

4.2. Implications for Future Research. Areas for furtherresearch include the following.

(1) Assessing global health competencies with franco-phone students in Canada using a French version ofthe survey.

(2) The use of qualitative and quantitative methods toevaluate students’ learning needs in relation to globalhealth knowledge, skills, and attitudes.

(3) Assessing the range of issues that relates to globalhealth that affects PT/OT practice during theirlocal/international training settings.

4.3. Considerations for Action. Based on our findings andthe current literature, considerations for action to improveglobal health education for rehabilitation students include thefollowing.

(i) Implementing and building on existing inter-profes-sional global health curriculum and mentorship pro-grams into, for example, the open access interdisci-plinary Refugees and Global Health e-Learning Pro-gram [35] and the Canadian Society of InternationalHealth StudentMentorship Program http://www.csih.org/en/about/job-opportunities/mentornet/.

(ii) Considering targeted admission policies to recruitstudents from different ethnic and language back-grounds over a range of socioeconomic status, as


there is evidence that workforce diversity may lead toimproved health care equity [36].

(iii) Providing opportunities for overseas global healthtraining, seminars, and workshops that couldimprove students’ knowledge and language skills,relevant to global health.

5. Conclusion

In conclusion, this paper expands our understanding of theemerging knowledge and skills that occupational therapyand physiotherapy students may need to provide fair andequitable health caremore effectively. It provides an invitationfor physiotherapy and occupational therapy educators andstudents to be more involved in emerging interdisciplinaryglobal health initiatives and considerations for the rehabilita-tion profession. In this globalized 21st century, it is essentialfor all health professionals to tackle determinants of health(e.g., socioeconomic, environmental, and political factors)and develop competencies to work with other disciplinesand to be globally interconnected to help reduce healthinequalities. Therefore, improving global health knowledgeand skills of occupational therapists and physiotherapists onglobal health competency is essential not only to prove carefor local socially disadvantaged and disabled populations, butalso to play leadership roles in the field of interdisciplinaryglobal health.

Conflict of Interests

The authors declare that they have no competing interests.

Authors’ Contribution

Mirella Veras, Kevin Pottie, and Peter Tugwell contributedto the study conception, design, and methodology. MirellaVeras, Tim Ramsay, and Govinda P. Dahal performed thestatistical analysis. Mirella Veras contributed to acquisitionof data and initiated the first and final draft paper. KevinPottie, Debra Cameron, and Govinda P. Dahal helped to draftthe paper. Kevin Pottie, Debra Cameron, Govinda P. Dahal,VivianWelch, and Peter Tugwell commented and gave expertadvice on the background, results, and discussion. All authorsread and approved the final paper.

Acknowledgments

This study was supported by the Canadian Institutes ofHealth Research (CIHR) as a part of the Fall 2009 DoctoralResearch Award Priority announcement in the Area of Pri-mary Care (Grant agreement no. 200910DPC-216158-DRB-CECA-187516).

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